Who You Treat: Adults

“It’s Not About the Nail”: confession of a problem-solver

When I was initially being trained to be a Suicide Prevention Call Specialist, I found it difficult to not jump right into problem-solving with the Caller. My law school education and professional experience as an attorney immediately triggered a need to identify the underlying problem and solve it. I struggled with simply listening to the Caller’s challenges and not offering ideas to “fix” them.

I was fortunate to have an in-house expert help me with this. Dave suggested I watch a short YouTube video (1 min 41 seconds) that was popular in 2013, called “It’s Not About the Nail”. It uses comedy and an outrageous demonstration to convey how “problem solvers” can be distracted by “fixable” problems, and as such, miss or ignore the pain and frustration of the person they are talking to.

I am not sharing this to make light of anyone struggling with mental health issues, but as a resource to “problem-solvers” like myself who find it hard to grasp that our problem-solving skills are not always helpful. If you choose to watch it, I hope you find it as eye-opening as I did.

It’s Not About the Nail

Colleen Kelly Jobes
Former Suicide Prevention LifeLine Call Specialist
Loss Survivor

Clinician-Survivors: The Peril and Promise of Risking to Care

Posted on by erics

Losing someone to suicide

As a clinician and suicide treatment researcher, I have contemplated for decades the prospect of losing someone to suicide. I regularly think about risking to care for people who struggle with thoughts of suicide. Like so many, I have personally known several people who have died by suicide. There was a painful loss of a friend and faculty colleague, who was literally across the hall from me. Tom took his life in the midst of four of us in my department conducting suicide research. Losing Tom was heartbreaking; the eyes of our graduate students were fixed on us faculty as they wondered how could you all have missed this? How could you have let this happen? I have often reflected on the moment a few days before Tom died when he stopped by my open office door to say “hi” and have a quick chat—something we both did countless times over the years as office neighbors. But this particular time after a brief exchange, Tom lingered at my door for a couple of beats as I turned to my computer to respond to my emails. In hindsight, I wish I had taken his subtle cue to invite him into my office to talk in more depth which was something we regularly did. But alas I did not and three days later Tom ended his life. Could my talking to him have prevented Tom’s suicide? I tell myself no, but I nevertheless regret what I failed to do in that moment, given what came to pass. I miss Tom both as a friend and faculty colleague.

Patients who are seriously suicidal

When I was in graduate school I worked as a Psych-Tech on an inpatient psychiatric unit. Within this role I helped avert several suicide attempts (two of which were patients on “15-minute checks” in the middle of hanging themselves in their rooms). While no one died, two patients came within a hair’s breadth of taking their lives. Some years later toward the end of my clinical internship within a V.A. Hospital, I gave a Rorschach Inkblot Test to a veteran who was deeply depressed. This patient struggled with the testing and we feared a closed head injury prompting us to pursue neuropsychology testing. But this testing never occurred because a few days after I met him, this profoundly depressed patient (a father of three young kids) laid down in front a bus as it departed from the hospital bus stop crushing him to death. Did I miss this patient’s potential for suicide? Yes, I had no inkling that this patient would soon be dead. I had met with him for 40 minutes before stopping the Rorschach given his abject inability to do the test. Do I have regrets about missing his suicide risk? Yes of course, but I do not blame myself for missing it.

Losing patients to suicide

As a practicing clinical psychologist for over 35+ years I have likely worked with thousands of patients in the V.A., in university counseling centers, and then as a private practitioner right up to the present day. Over my career, I have seen and treated hundreds of patients who have been suicidal. And while I have cut back on my clinical practice, I still see a couple of patients who are periodically suicidal. Over these years, I have had a half dozen patients make suicide attempts, a few of which could have been fatal but for twists of fate. As I reflect on clinical practice, I have no illusion that I will not lose a patient to suicide just because I am an expert on the topic. When it comes to suicide, no provider is infallible. Indeed, two of my beloved mentors lost patients to suicide. The late Dr. Terry Maltsberger, known for his seminal work on suicide-related countertransference, worked at McLean Hospital and Harvard Medical School, and he maintained a vibrant private practice. Over his career Terry counted himself “lucky” for never losing a patient to suicide after decades of seeing countless patients whom were highly suicidal. But then Terry lost a private practice patient shortly before he retired. Over the years that Dr. Marsha Lineman developed DBT within randomized controlled trials (RCTs), she always saw high risk patients and lost several of her patients to suicide. Thus, even these giants of clinical suicidology were not immune to losing patients.

The need for evidence-based treatment

In more recent years as I have dialed back my clinical practice, I have expanded the clinical trial research of CAMS, resulting in 9 published open clinical trials, 5 published RCT’s, along with two independent meta-analyses that support the effectiveness of CAMS. Given the risk, it is perhaps not surprising that we have also lost 4 patients to suicide who were in CAMS clinical trials. A particularly painful reality for my graduate students and me is watching sessions (on a secure platform) to ensure that CAMS providers are adherent and that RCT fidelity is assured. But in watching these cases for research purposes, we get drawn in and care about the clinicians and their patients. In one particularly challenging case, a CAMS study patient received over 20 sessions only to take her life as she seemed to deteriorate on video before our eyes. This death occurred despite an adherent provider who heroically used CAMS with the best consultation we could provide. We were heartbroken by this patient’s suicide and a tearful grad student asked me, “…after all these years, how do you handle a suicide like this?” My answer: “While losing this patient breaks my heart, and sobers me, it does not deter me from doing what we are doing…and actually it compels me to work even harder…we are not going to not do this kind of research because of this tragedy…we have to remember that we have helped save many more lives than we have lost and that fact keeps me going so others do not have to die this way.”

Using CAMS can help clinical confidence and may comfort family

I have a colleague who attended two early trainings of CAMS and she routinely used it in her counseling center work. After much success using CAMS with counseling center clients, she saw a grad student in chemistry who had a serious history of suicide risk (including two inpatient stays). The provider engaged this client in CAMS for six sessions, but the patient used an “exit-bag” to take his life by inhaling helium. In the midst of her grief, the clinician reached out to me for consultation and together we reviewed de-identified copies of the client’s SSFs during a phone consultation. With the wisdom of hindsight, I noted a few observations for improvement, but overall I felt that the clinician did an excellent job and she was certainly adherent to model. During our call I shared my heartfelt support and gave her encouraging feedback as I expressed my sincere condolences. I reassured her that she had done right by this client. Some six months later, this clinician re-contacted me for a follow up consultation in which I learned that the client’s parents had come across a file folder in their son’s desk entitled “Therapy” with copies of his SSF’s from his CAMS sessions. In that same folder was a printout of internet information about obtaining and then using an exit bag for suicide. The clinician told me that she spoke to the mother, and later the father who joined the 2-hour phone call. Towards the end of the call the bereft mother asked the provider, “…and what can we do for you? Because of course you lost our son too…are you doing okay?” The father finally noted, “…at least we have the comfort of knowing that the counselor who saw our son did not have her head in the sand when it comes to suicide…thank you for what you tried to do for him.”

The risk to care is worth it

When working with suicide risk there are obviously perils and the potential for heartbreak which must be balanced with the promise and rewards of life-saving care. One does not come without the other. What keeps me going is a grim acceptance that no clinician is immune to losing a patient. But I do take comfort and draw strength to persevere in the knowledge that I am able of provide the best possible care that I know to render. What more could I ever aspire to do when faced with the perils of suicide? For me, the risk to care continues to be worth it, because it can literally mean the difference between a death and saving a life. And I find great inspiration in doing right by my patients and endeavoring to foster that same feeling in other providers so they too can provide the best possible care to help save lives.

Why do Black Males Consider Suicide?

Why do Black Males Consider Suicide? On-Demand Webinar

Suicidologists have focused on the quality and reproducibility of the science of why people die by suicide. Dr. Sean Joe, a social work scientist, highlights the emerging science on suicidal behavior among Black Americans, calling attention to important roles of sex and age that reflect not only differences in etiology, but also other important variations in relation to risk, the nature of suicidal behavior and its prevention and practice with Black boys and young men.

Dr. Sean Joe, PhD, MSW

About Dr. Sean Joe, PhD, MSW

Dr. Joe is a nationally recognized scholar on suicidal behavior among Black Americans, particularly regarding the role of firearms as a risk factor and is expanding the evidence base for effective practice with Black boys and young men. His research focuses on Black adolescents’ mental health service use patterns, epidemiology and prevention of Black suicidal behavior, and family-based interventions to prevent urban Black American adolescent males from engaging in multiple forms of self-destructive behaviors.

Dr. Joe is the President of the Society for Social Work and Research (SSWR), whose members represent more than 200 universities and institutions, 45 states in the United States as well as from 15 countries. SSWR advances, disseminates, and translates research that addresses issues of social work practice and policy and promotes a diverse, just, and equitable society. Dr. Joe is a Fellow of the American Academy of Social Work and Social Welfare, the Society for Social Work and Research, and New York Academy of Medicine. He serves on the Steering Committee of the national Suicide Prevention Resource Center (SPRC), Standards, Training and Practices Committee of the National Suicide Prevention Lifeline, and the Scientific Advisory Board of the American Foundation for Suicide Prevention.

As founding Director of the Race and Opportunity Lab, which examines race, opportunity, and social mobility with an emphasis on informing policies, interventions, and intra-professional practice to lessen ethnic inequality in adolescents’ healthy transition to adulthood. The lab leading community science project is HomeGrown STL, which is a multi-systemic placed-based capacity building intervention to enhance upward mobility opportunities and health of Black males ages 12-29 years in the St. Louis region. His epistemological work focuses on the concept of race in medical and social sciences.

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Suicide Status Form Intake: Integrating a Culturally Informed Interview Process

What is the Suicide Status Form?

The Suicide Status Form (SSF) is part of the Collaborative Assessment and Management of Suicidality (CAMS) completed in conjunction with the client’s sessions. This form helps assess the client, acquire suicidal behavior history, and create an individualized treatment plan. The Suicide Status Form is 1) a tool to integrate the client as an active participant in the therapeutic process and 2) a guide to creating a comprehensive suicide prevention model for the client-clinician.

The initial intake session provides the foundation, developing trust and engagement. For minority clients, the intake can be an intimidating process due to increased exposure to systemic disparities, mental health biases, and marginalization.1 The effectiveness of the SSF is found within its collaborative approach.2 Efficacious and valid treatment for marginalized clients centers client-focused and culturally informed treatment.3 This article is a comprehensive guide to formulating culturally informed questions and feedback during the interview process.

Section A of the Suicide Status Form: Psychological Assessment

Section A of the Suicide Status Form is an assessment of the client’s current suicidal behavior. This section is the baseline of the clinician-client relationship and guides the outcome of the intake. In this section, the client is directly involved in the response of the assessment, while the clinician guides the client. The collaborative approach establishes client autonomy, intimacy, and vulnerability between the clinician-client. Provided below are suggestions for culturally informed questions and feedback for Section A of the SSF:

  • Rate Psychological Pain

    In my experience working with minority clients, the question of “psychological pain” can be difficult to answer. This is potentially due to the stigma of openly talking about suicidal behavior.4 It helps to reframe the discussion as one about physical pain, which then directs the conversation toward disclosing suicidal thoughts.

    “When you begin feeling like hurting yourself, can you share with me where on your body you feel that pain most?”

  • Rate Stress

    Stress can result from both internal and external factors. It can also result from structural factors such as systemic and institutionalized disparities.5 Establishing an interview process which acknowledges the multiple factors of stress on the client’s mental health supports an effective, individualized treatment plan.

    “I acknowledge that there are external stressors and situations that might impact your suicidal behavior. I would like you to know as we proceed with treatment that this is a safe space for you to share those stressors with me, without judgement”.

  • Rate Self-Hate

    See above. As the client measures self-hate, it is suggested to frame the conversation by acknowledging both internal and external factors.

  • Thoughts and Feelings about Suicidal Behavior

    It is important to consider that clients from underserved populations may have a history of experiencing stigmatization and other disparities during previous encounters with mental health providers.6 This may present itself in the form of distrust, lack of engagement, and discomfort with the therapeutic process. In reducing these responses, the provider can discuss the procedures of disclosure and confidentiality to re-affirm trust with the client.

    “We are beginning to discuss more about your suicidal thoughts. This means we are going to talk about what makes you feel suicidal. Before we go any further, do you have any questions about the process?”

  • Reasons to Live; Reasons to Die

    For some cultures, openly discussing suicidal thoughts is taboo. The reasons for these taboos range from beliefs of “keeping things in the family” to limitations with psychoeducation. This section is an intentional approach in comprehending the cultural, social, and individual factors that impact the client’s suicidality. For some clients, this is expressed in community and family being a protective and/or risk factor for suicidal behavior. The family/community might be a support system, but also can represent stressors to the client. Discussing these dynamics with the client will be helpful in future sections of the SSF.

    “Thank you for sharing your experiences with me. I can understand this process has been very difficult, and I thank you for being open to the process. We are going to move at your pace, so if you need a moment, we can take a break. I am here to support you, and sharing how you feel is valid.”

Section B: History of Suicidal Behavior

This section of the Suicide Status Form is where the clinician and client discuss the client’s history of suicidal behavior. This section also details the history of physical and mental health, as well as interpersonal and socio-economic factors that may influence a client’s suicidality. The responses to this section will influence the treatment plan in Section C. Provided below are suggestions for culturally informed questions and feedback for Section B of the SSF:

  • Reliving and discussing these factors might be traumatic to the client. Continuing to re-affirm and validate the client’s openness is beneficial.
  • Burden to Others. Help-seeking behavior is reduced in racial minorities due to a multitude of factors, such as sense of burden on their family/community, fear of the mental health system, and experiences with discrimination.7
  • History of Legal/Financial Issues. When discussing a client’s socioeconomic status, consider that financial stressors may impact a client’s ability to receive mental health support or contribute as a risk factor. Discussing the financial stressors of therapy is important in reducing overall stressors.

Section C: Treatment and Stabilization Plan

Following the responses from Section A and B, Section C of the Suicide Status Form is where the client and clinician work on establishing an individualized treatment plan. CAMS effectively integrates the client into the therapeutic process with its collaborative approach, which aids in establishing the treatment plan. Provided below are suggestions for culturally informed questions and feedback for Section C of the SSF:

  • Confusing Terminology

    In my experience, I have found that terminology can be confusing to clients. At this stage, the clinician needs to thoroughly explain the treatment plan and ask clients if they have any questions.

    “I understand we have been sharing a lot today and that can be overwhelming. We have discussed your thoughts of suicide and your history. Now, I want to share your treatment plan for the remainder of your time with me. I can explain, and if you have any questions, we can discuss them. How do you feel about this plan?”

  • CAMS Stabilization Plan

    As we have established in Section A, family/culture are very important aspects of an individual’s treatment, especially for racial/ethnic minorities.8

    This means for some individuals the support system can be represented by external community services (i.e., therapist, social worker, support group, etc.). For others, the support system might include a complex network of friends, family, and religious/spiritual leaders.

  • Potential Barriers to Treatment

    In section A, we discussed the potential barriers to accessible treatment. I suggest extending the conversation by asking about potential social and structural stressors that may hinder the client’s accessibility to your services. This might include lack of steady transportation, disability restrictions, unsafe family environments, lack of housing, financial instability, and a plethora of other societal factors. Having an early discussion to talk about minimizing those barriers will increase client retention and build trust.

Section D: Clinician Evaluation

In the final intake section of the Suicide Status Form, the clinician provides post-sessions evaluations of the client’s behavior and mental status. Provided below are suggestions for culturally informed questions and feedback for Section D of the SSF:

  • While evaluating a client’s behavior and mental status, the clinician should reflect on their evaluation. Understand that biases and assumptions are a human reality. Our positionality influences our thoughts, ideologies, and assumptions. Check in to see if you are interpreting a certain body language, tone, or response with an open mind. For example, what might be perceived as aggression or hostility to a clinician might be a cultural expression of sadness or pain. Being informed on cultural expressions reduces mental health disparities and implicit biases.

Conclusion: Becoming a Culturally Informed Clinician

To be a culturally informed clinician means that the mental health provider acknowledges and integrates their client’s cultural identity into the treatment. It is not about being a professional anthropologist but being open to exploring and discussing the impact of social identity. This is important in establishing an effective treatment plan. The Suicide Status Form builds a collective understanding of a client’s suicidal thoughts, history, and individualized treatment. The recommendations in this article are a comprehensive guide in forming a culturally informed intake process.

  1. https://www.apa.org/pi/oema/resources/brochures/treatment-minority.pdf
  2. https://cams-care.com/resources/educational-content/vermonts-zero-suicide-initiative/
  3. Foundations of Multicultural Psychology: Research to Inform Effective Practice, by T. B. Smith and J. E. Trimble Copyright © 2016 by the American Psychological Association
  4. https://www.nimh.nih.gov/news/media/2020/responding-to-the-alarm-addressing-black-youth-suicide
  5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6532404/
  6. https://www.journals.uchicago.edu/doi/pdfplus/10.5243/jsswr.2010.10
  7. Addressing Mental Health in the Black Community | Columbia University Department of Psychiatry (columbiapsychiatry.org)

About the Author

Tanisha Esperanza Jarvis M.A.

Tanisha Esperanza Jarvis M.A.
Tanisha Esperanza Jarvis received her B.A. in anthropology and sociology at Spelman College in 2015, where she also minored in Comparative Women’s Studies. While at Spelman, her research focused on integrating academia and social justice. As a Bonner Scholar and Social Justice Fellow her research work included preventative and interventional treatment of sexual trauma and LGBTQ and racial/ethnic minority research. She finished her M.A. in psychological sciences from The Catholic University of America (CUA) in 2019. Her research within the Suicide Prevention Lab (SPL) focused on integrating an international approach to CAMS research and treatment of suicidality within marginalized communities.

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About Tanisha Esperanza Jarvis M.A.

Tanisha Esperanza Jarvis M.A.
Tanisha Esperanza Jarvis received her B.A. in anthropology and sociology at Spelman College in 2015, where she also minored in Comparative Women’s Studies. While at Spelman, her research focused on integrating academia and social justice. As a Bonner Scholar and Social Justice Fellow her research work included preventative and interventional treatment of sexual trauma and LGBTQ and racial/ethnic minority research. She finished her M.A. in psychological sciences from The Catholic University of America (CUA) in 2019. Her research within the Suicide Prevention Lab (SPL) focused on integrating an international approach to CAMS research and treatment of suicidality within marginalized communities.

Podcast: To Hospitalize or Not to Hospitalize, the Question Most Therapists Struggle with in Helping Clients with Suicidality

Episode Summary

In this interview, Dave discusses his career in researching suicide and how Marsha Lineman encouraged him to go beyond his assessment work to create an intervention for therapists working with clients who are suicidal. He discusses how many therapists struggle to know how to effectively assess suicide risk and intervene in a manner that can build the therapeutic relationship as well as keep clients safe. He explains that due to lack of training, knowledge of evidence-based interventions, and fear, therapists often jump to hospitalizing their clients, when it may not be necessary, and he challenges the overall utility and effectiveness of hospitalization altogether. Dave discusses his clinical tool and intervention, the Suicide Status Form (SSF-4) and his Collaborative Assessment and Management of Suicidality (CAMS), which have been found to decrease suicidal risk in patients through randomized controlled trials. He explains that therapists can effectively treat suicidality through collaboration, being clear and transparent on the limits of confidentiality and what may lead to a hospitalization. His intervention helps reduce access to lethal means as well as the value of identifying and treating patient-defined “drivers” for suicide, which research shows leads to decreasing hopelessness while increasing hope. The topics of suicidal ideation vs. suicidal intent are discussed and how ideation in itself is sometimes a form of coping. He speaks to the most feared situations where the therapist is not sure if the client can be sufficiently stable for outpatient care, and he addresses cases in which clients who take their life despite all clinical best efforts. Dave encourages therapists to become more competent in suicide assessment and treatment, because even though clinicians may screen for suicide when accepting patients, it is inevitable that they will have clients who are suicidal. He argues that suicide risk being “not something I work with,” is a problematic stance as it reflects an unwillingness to work with the one fatality of mental health.

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About the Author

David A. Jobes Ph.D. ABPP

David A. Jobes Ph.D. ABPP
David Jobes, PhD, ABPP, is the founder of CAMS-care, LLC. He began his career in 1987 in the Counseling Center of the Catholic University of America, where he developed a suicide risk assessment tool for college students that evolved into CAMS. Dr. Jobes is now a Professor of Psychology and Associate Director of Clinical Training at Catholic; he has trained thousands of mental health professionals in the United States and abroad in evidence-based assessment and treatment of suicide risk and the use of CAMS.

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About David A. Jobes Ph.D. ABPP

David A. Jobes Ph.D. ABPP
David Jobes, PhD, ABPP, is the founder of CAMS-care, LLC. He began his career in 1987 in the Counseling Center of the Catholic University of America, where he developed a suicide risk assessment tool for college students that evolved into CAMS. Dr. Jobes is now a Professor of Psychology and Associate Director of Clinical Training at Catholic; he has trained thousands of mental health professionals in the United States and abroad in evidence-based assessment and treatment of suicide risk and the use of CAMS.

Telehealth: A Critical Tool for Treating Suicidal Risk On-Demand

Telehealth: A Critical Tool for Treating Suicidal Risk On-Demand Webinar

In this hour-long webinar, “Telehealth: A Critical Tool for Treating Suicidal Risk”. Dr. David Jobes, the creator of the Collaborative Assessment and Management of Suicidality, discusses the benefits of telehealth using evidenced based treatment. 15,000,000 adults and youth in the US struggle with serious thoughts of suicide. Thoughts matter and telehealth is a critical tool in working with this population.

Hosted by Dr. Kevin Crowley, clinical psychologist, private practitioner and CAMS Consultant.

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Suicide Risk: Effective Clinical Assessment, Management, & Treatment

Posted on by erics

Major misunderstandings about clinical care related to suicidal risk tend to exasperate me a bit. Let me therefore address and clarify some common misunderstandings that can interfere with saving lives. The key constructs at hand are assessing suicidal risk, managing acute risk, and treating suicidal risk.

The Importance of Assessing Suicidal Risk

While it’s true that we cannot reliably predict future suicidal behaviors, assessing suicidal risk remains a crucial step in preventing suicide. The goal of suicide risk assessment is to identify individuals who may be at risk for suicide and develop a safety plan to prevent suicide.

It’s important to differentiate between screening and assessment. Suicide screening is a brief assessment of an individual’s risk for suicide, whereas suicide assessment involves a more comprehensive evaluation of an individual’s suicide risk. Both screening and assessment are important in identifying individuals at risk for suicide and ensuring they receive appropriate care.

Suicide Screening in Managing Suicidal Risk

Identifying individuals who may be at risk for suicide is crucial to save lives, and suicide screening is an effective approach to achieve this goal. Suicide screeners consist of a set of standardized questions or tools that are used to quickly identify individuals who may be at risk for suicide. The aim is to detect the prospect of suicidal risk using a short screener of questions.

ASQ and C-SSRS are two widely used suicide screeners with solid psychometrics, normed on both youth and adult populations. Developed by Dr. Lisa Horowitz at NIMH and Dr. Kelly Posner at Columbia University, respectively, these screeners are non-proprietary and available online. They have various versions for different populations and needs.

Although PHQ-9 is a free online screener, it was originally developed as a depression assessment and is therefore not a perfect screener for suicide risk. Suicide screeners such as ASQ and C-SSRS are preferred due to their psychometric robustness and suitability for suicide risk assessment.

Suicide Risk Screening vs. Suicide Assessment: Understanding the Difference

It is important to understand the difference between suicide risk screening and suicide assessment. Suicide risk screening involves the use of a standardized set of questions or tools to quickly identify individuals who may be at risk for suicide. In contrast, suicide assessment is a more in-depth process that involves the use of longer versions of suicide-specific assessment tools, along with clinical interviewing and relying on a clinician’s clinical judgement.

The C-SSRS is an example of a suicide-specific assessment tool that has longer versions for assessing suicide risk. However, there are many other proprietary assessment tools available that are not widely used. Research has shown that while clinicians prefer relying on their gut judgments, these assessments are never as good as actuarial assessment scales.

It is important to note that suicide risk screening and assessment are not the same as treatment. They are only the start of the process of identifying and addressing suicide risk. Clinicians should be aware of the different suicide screening and assessment tools available to provide the best care for their patients.

Managing Acute Suicidal Crises: The Importance of Intervention

Interventions for managing acute suicidal crises are not a substitute for treatment or assessment. To help individuals in crisis, the Safety Plan Intervention (SPI) developed by Dr. Barbara Stanley and Dr. Greg Brown is widely used and proven to be more effective than the outdated “no-harm/no-suicide” contract. Another tool, the Crisis Response Plan (CRP) developed by Dr. David Rudd and studied by Dr. Craig Bryan, also shows promise in reducing suicidal ideation and suicide attempts. A recent meta-analysis of safety planning studies in Europe confirms that such interventions significantly reduce suicide attempts. However, it’s essential to note that managing an acute crisis is just the beginning and not equal to treating suicide risk.

Treating Suicidal Risk: DBT, CT-SP, BCBT & CAMS

Treating suicide risk is a critical aspect of suicide prevention. Several proven interventions have been developed and tested through randomized controlled trials (RCTs) by independent investigators. Dialectical Behavior Therapy (DBT) is effective in reducing suicide attempts and self-harm behaviors. Cognitive Therapy for Suicide Prevention (CT-SP) and Brief Cognitive Behavioral Therapy (BCBT) have both shown significant reductions in suicide attempts. However, these interventions are not necessarily effective in reducing suicidal thoughts. On the other hand, the Collaborative Assessment and Management of Suicidality (CAMS) is the most supported intervention for treating suicidal thoughts, with five published RCTs, nine published non-randomized clinical trials, and a new independent meta-analysis of nine CAMS trials. It is important to note that treating suicidal risk is not a one-size-fits-all approach, and treatment should be tailored to the individual’s specific needs.

* * * * *

In summary, some of my biggest professional frustrations around clinical misunderstandings related to suicide risk are implied above but permit me to spell them out plainly:

  1. Simply doing a suicide screening and/or an assessment is not an intervention.
  2. Having a patient complete a Safety Plan is not treatment.
  3. Many treatments used for suicidal risk have little to no empirical support (e.g., medications and inpatient hospitalizations).
  4. Not all suicide-focused treatments impact all aspects of suicidality (e.g., behaviors vs. ideation).

‘

The CAMS Approach: Effective Suicide Risk Assessment, Management, and Treatment

When it comes to suicide prevention, effective risk assessment, management, and treatment are critical. While the C-SSRS is an excellent screener and assessment tool for detecting suicide risk, it is not a treatment for suicidal risk. That’s where the Collaborative Assessment and Management of Suicidality (CAMS) approach comes in. CAMS is a proven, suicide-focused clinical intervention that includes both assessment and treatment components, with extensive empirical support.

One of the unique features of CAMS is its ability to function as a “therapeutic assessment” experience. It also manages and treats suicidal individuals better than any other clinical treatment available, with promising data on suicide attempts and self-harm as well. CAMS is not a one-size-fits-all solution, but it is an excellent option for the largest population in the field of suicide prevention: the 12 to 14 million Americans of all ages who experience serious thoughts of suicide.

Using CAMS can help clinicians avoid common clinical misunderstandings and ensure better clinical care, potentially leading to life-saving outcomes. So while the C-SSRS is a valuable tool for detecting suicide risk, it is important to remember that it is not a treatment. CAMS, on the other hand, is a proven approach that can effectively assess, manage, and treat suicidal risk.

When It is Darkest: Why People Die by Suicide On-Demand

When It is Darkest: Why People Die by Suicide: On-Demand Webinar

Based around his new book, Dr. Rory O’Connor will try to dispel myths around suicide. He will also describe the complex set of factors that can lead to suicide, drawing from the innovative Integrated Motivational-Volitional Model of Suicide. Dr. O’Connor will end with an overview of what we can do to support those who are vulnerable.

Dr. Rory O'Connor

About Dr. Rory O’Connor

Rory O’Connor PhD FAcSS is Professor of Health Psychology at the University of Glasgow in Scotland, President of the International Association for Suicide Prevention and a Past President of the International Academy of Suicide Research. Rory leads the Suicidal Behaviour Research Laboratory (Web: www.suicideresearch.info; Twitter: @suicideresearch) at Glasgow, one of the leading suicide/self-harm research groups in UK. He also leads the Mental Health & Wellbeing Research Group at Glasgow. He has published extensively in the field of suicide and self-harm, specifically concerning the psychological processes which precipitate suicidal behaviour and self-harm. He is also co-author/editor of several books and is author of When It is Darkest. Why People Die by Suicide and What We Can Do To Prevent It (2021). He is Co-Editor-in-Chief of Archives of Suicide Research and Associate Editor of Suicide and Life-Threatening Behavior. Rory acts as an advisor to a range of national and international organisations including national governments on the areas of suicide and self-harm. He is also Co-Chair of the Academic Advisory Group to the Scottish Government’s National Suicide Prevention Leadership Group.

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CAMS Meta-Analysis: Intervention for Suicidal Ideation

Posted on by erics

I am delighted to blog about a brand-new meta-analysis of nine clinical trials showing robust support for the Collaborative Assessment and Management of Suicidality (CAMS). This landmark article has just been published in the suicide prevention field’s premier peer-reviewed scientific journal, Suicide and Life-Threatening Behavior.

The CAMS meta-analysis project was led by Dr. Joshua Swift, a well-established psychotherapy treatment researcher, and Associate Professor of clinical psychology at Idaho State University (ISU). Dr. Swift, along with two graduate students, pursued a rigorous meta-analysis of CAMS clinical trials during the summer of 2020, submitting their manuscript for peer-review in the fall. This meta-analysis was sponsored by CAMS-care, LLC with the goal of supporting an independent research laboratory to conduct a demanding and labor-intensive meta-analysis (which is a large study of various studies that meet certain specific selection criteria). It is noteworthy that Swift and his team are not suicide treatment researchers, which helped ensure a fresh and unbiased perspective to this rigorous scholarly undertaking.

To conduct this meta-analysis, the ISU research team identified over 1,000 published and unpublished articles, theses, and dissertations that referred to “CAMS” or “SSF” (the Suicide Status Form is a multipurpose assessment and treatment tool used within CAMS). Using certain selection criteria (e.g., empirical clinical trial data vs. conceptual; having a comparison control group design vs. no control comparison), the team eventually identified and selected nine clinical trials of CAMS comparing it to control treatments, such as “treatment as usual” (TAU) and one Danish trial comparing CAMS to Dialectical Behavior Therapy (DBT). Once the selected studies were identified, the team performed a series of statistical analyses across the studies to investigate the relative effect sizes related to clinical treatment outcomes (i.e., a measure of the relative impact of the interventions on certain key outcome variables). In other words, the overall impact of study treatments within and across all the selected clinical trials can all be compared within a meta-analysis (additional analyses related to “moderator effects” were also studied).

The results of their efforts were impressive. The research team found that, in comparison to control treatments, CAMS caused significant reductions in suicidal ideation and overall symptom distress while positively impacting hope/hopelessness and increasing treatment acceptability. There was non-significant—but trending—support for its positive impact on suicidal attempts, self-harm, and cost-effectiveness (but more data are needed to see if these effects could reach statistical significance). Importantly, in none of the nine selected clinical trials of CAMS was comparison treatment ever better than CAMS when overall “weighted averages” across studies for each clinical outcome were calculated. There were no significant differences between the use of CAMS with white vs. non-white patients (but more diverse clinical samples are needed; the European CAMS studies to date have primarily had patients who were Caucasian).

Interestingly, the clinical trials in which I (as the creator of CAMS) was directly involved did relatively worse than ones in which I was not involved! Thus, there is no “publication bias” or “allegiance effects,” which underscores the scientific objective nature of the meta-analysis evidence supporting CAMS. Dr. Swift’s team ultimately concluded that CAMS is “Well Supported” as a clinical intervention for suicidal ideation as per Center for Disease Control criteria (which is the highest level of empirical support).

Review the original article by Dr. Swift: The effectiveness of the Collaborative Assessment and Management of Suicidality (CAMS) compared to alternative treatment conditions: A meta-analysis

So, what does all this rigorous research of various clinical trials actually mean? In short, this meta-analysis of CAMS is a breakthrough investigation that caps off almost 30 years of hard-earned clinical trial research, which first focused on the early use of the SSF that later evolved into the suicide-focused clinical intervention that CAMS has become. This meta-analysis convincingly confirms that using this suicide-focused therapeutic framework works for many patients who are suicidal around the world and in different treatment settings (e.g., outpatient settings, crisis clinics, and inpatient settings). It confirms that emphasizing the four “pillars” of CAMS—collaboration, empathy, honesty, and being suicide-focused—is indeed a proven way of reliably decreasing suicidal ideation and reducing serious psychiatric distress.

One of my favorite findings from the meta-analysis is that the most robust weighted average was for the outcome of decreasing patients’ hopelessness while increasing their hope! This is an important finding about which I have previously blogged. For me, the publication of this independent and rigorous study is a career highlight and a convincing testament to the effectiveness of CAMS for patients who are suicidal around the world across a range of clinical settings. We can now say with confidence that CAMS effectively treats the most significant challenge that we face in the field of suicide prevention today: the massive population of people who struggle with serious thoughts of suicide. Given the evidence, we believe that CAMS can effectively treat the “iceberg” of people with suicidal thoughts, a population 225 times greater than the population of those who take their life (Reflections on Suicidal Ideation). If we succeed in our efforts to train more clinicians to provide “upstream” effective CAMS-guided care to those who struggle with serious suicidal thoughts, perhaps we can help divert such patients from going on to attempt suicide or even prevent them from suicide further “downstream.” Thus, the publication of this new meta-analysis supporting the use of CAMS by Swift and colleagues is a major breakthrough to realizing the ambitious goal of reducing suicide-related suffering in all its forms around the world.

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Background on the CAMS Framework

CAMS is a therapeutic framework for effectively treating suicidal risk. It evolved from a line of suicide risk assessment research that initially began at the University Counseling Center at The Catholic University of America in the late 1980s. The key tool in CAMS is the Suicide Status Form (SSF) which guides all clinical activity within the intervention—from the initial session, across all interim care, to the outcome/disposition session, which concludes the use of CAMS. The SSF, therefore, functions as a multipurpose assessment, treatment planning, tracking, to clinical outcome tool. Previous research has shown that the SSF serves as a “therapeutic assessment.” CAMS SSF-based treatment planning focuses on patient-identified suicidal “drivers,” which are the problems that compel them to consider suicide (e.g., a relational breakup or self-hate). CAMS, therefore, targets and treats the patient’s suicidal drivers over the course of care to achieve optimal clinical outcomes such as rapid reduction of suicidal thoughts (in as few as 6-8 sessions), decreased symptom distress, and decreased hopelessness with increased hope.

CAMS’s Purpose and Function

The purpose of CAMS is to engage a person who is suicidal in a strong therapeutic clinical alliance while increasing their motivation to be an active collaborator within their tailored suicide-focused care. CAMS thus functions as a guiding framework to help stabilize the patient’s life while suicidal drivers are addressed and treated throughout the course of care. CAMS concludes with a focus on purpose and meaning and the pursuit of a life worth living.

How Clinicians Utilize CAMS

Clinicians across a range of clinical settings use CAMS to effectively stabilize and treat patients who are suicidal. The framework is atheoretical, which means that it is not tied to a particular theoretical orientation or set of techniques. The SSF provides structure for assessing suicidal risk at the start of each session and ensures that the suicide-focused treatment plan is updated at the end of every CAMS-guided session. The SSF also helps create extensive medical record documentation that reflects effective suicide-focused assessment, treatment planning, and follow-through. This kind of documentation reflects good practice and helps decreased the risk of malpractice liability related to working with patients who are suicidal.

Why CAMS is Effective in Reducing Suicidal Ideation and Associated Issues

Research has clearly shown that when CAMS is used adherently, it reliably reduces suicidal ideation and overall symptom distress, while increasing hope, and improving retention to clinical care. While more research is needed to understand the exact mechanisms of CAMS, we believe that a strong clinical alliance along with empathy and validation are essential ingredients to all successful CAMS-guided care. Research also shows that CAMS seems to change the patient’s “relationship” to suicide, providing alternative coping methods and getting needs met. Beyond helping patients become less suicidal, CAMS also encourages patients towards the end of care to actively consider the pursuit of plans, goals, and hope for the future within a life worth living—a “post-suicidal” life—a life with purpose and meaning.

The Need for Effective Suicide Interventions

There are remarkably few proven-effective clinical treatments for patients who are suicidal. Many practitioners rely on inpatient hospitalizations and psychotropic medications which have limited to no evidence for being effective with suicidal risk. Other effective treatments like Dialectical Behavior Therapy (DBT) or suicide-specific Cognitive-Behavioral Therapy (CBT) are more effective with decreasing suicide attempts, whereas CAMS reliably treats the much larger population of people with serious suicidal thoughts. Moreover, CAMS is relatively easy to learn compared to DBT and CBT and is generally more flexible and adaptable to different settings and theoretical orientations compared to other effective suicide treatments.

The Merit of CAMS is Undeniable

CAMS is a proven and effective treatment that is relatively easy to learn and ensures good practice and documentation that helps decrease practitioner exposure to liability. Research has shown that patients significantly prefer CAMS to usual care, and training in CAMS has been shown to increase provider competence and confidence, which are critical to successful care.

Case Example

In a randomized controlled trial of CAMS conducted at a U.S. Army infantry post, there was a multiply deployed Soldier “John” who came into treatment after being referred by his commander. John had significant combat-related trauma, and he was extremely upset that his ex-wife was moving to another state taking their two young sons. His CAMS clinician—a skilled clinical social worker—engaged him with the SSF in the first CAMS session. They readily identified his suicidal drivers: combat-related PTSD and the potential loss of access to his sons.

Over the course of ongoing interim CAMS care, the clinician effectively treated the Soldier’s PTSD with cognitive processing therapy (CPT). The clinician also arranged for the Soldier to meet with a JAG officer to receive legal consultation related to gaining joint child custody. Beyond treating his drivers, a significant issue with this Soldier was the clear need for John to leave the Army because of his inability to engage in further combat deployments (given the PTSD from his four previous combat deployments). During interim CAMS sessions, the clinician was able to gently persuade John to consider a medical separation from the Army, and together they engaged a VA provider who could see John after separation. They also explored various job options he could pursue as a civilian. Within a few weeks, with legal help from JAG, John obtained joint custody of his children and secured an arrangement for parental visitations. By session 9 of CAMS, John no longer had suicidal thoughts. While he was sad to leave the Army, John was excited about some job opportunities and the prospect of getting an associate degree with his VA benefits. John’s suicidal ideation had significantly resolved in fairly short order, and his symptoms of PTSD and anxiety were notably reduced. John actually felt hopeful about his future and ultimately became eager to leave the Army for a promising life outside the military.

In John’s case, we see all the elements of what Swift et al. found within their landmark meta-analysis of nine CAMS clinical trials. At the conclusion of CAMS, John began to realize a post-suicidal life—one with promise and potential for having successfully completed a therapeutic course of CAMS-guided care. While there were no doubt challenges ahead, John found his way out of a suicide crisis that put his life in peril. After his treatment, John saw that there could be life beyond being a Soldier,; a life with purpose and meaning—a life worth living.

CAMS Meta-Analysis: Intervention for Suicidal Ideation

Dr. Joshua K. Swift

Published: May 17, 2021

A recent rigorous meta-analysis of the Collaborative Assessment and Management of Suicidality (“CAMS”) showed that it is a “Well Supported” intervention for reducing suicidal ideation per CDC criteria.

The meta-analysis was performed by Dr. Joshua K. Swift and his team at the Department of Psychology at Idaho State University. It included nine studies, primarily randomized controlled trials, with data from 749 patients where the CAMS intervention was compared to treatment as usual or, in one study, with Dialectical Behavior Therapy (“DBT”). The new study has just been published in the peer-reviewed journal, Suicide and Life-Threatening Behavior.

“The results showed that CAMS, in comparison to alternative interventions, resulted in significantly lower suicidal ideation and general distress, considerably higher treatment acceptability, and notably higher hope/lower hopelessness,” Dr. Swift explained.

Review the original article by Dr. Swift: The effectiveness of the Collaborative Assessment and Management of Suicidality (CAMS) compared to alternative treatment conditions: A meta-analysis